Botulinum Toxin A Versus Bilateral Medial Rectus Recession for Partially Accommodative Esotropia: A Systematic Review and Meta-analysis

Purpose: To perform a systematic review and meta-analysis comparing the efficacy of botulinum toxin A (BTX-A) and bilateral medial rectus recession (BMR) surgery for partially accommodative esotropia (PAET). Methods: PubMed, EMBASE, and the Cochrane database were searched on May 29, 2024 for studies comparing BTX-A and BMR in patients with PAET, reporting at least one outcome of interest. The odds ratio (OR) and 95% CI were used for binary outcomes. Heterogeneity was assessed using I 2 statistics. The analysis was performed using R software version 4.3.2. The Risk of Bias Summary for Non-randomized Studies tool was used to assess the risk of bias. Results: Four observational studies comprising 521 patients were eligible for inclusion. BTX-A and BMR groups had comparable motor success rates (OR: 1.14; 95% CI: 0.27 to 4.81; P = .861; I2 = 88%). However, consecutive exotropia was reported exclusively after BMR only (OR: 0.08; 95% CI: 0.01 to 0.46; P = .004; I 2 = 0%). All studies accounted for heterogeneity in the leave-one-out sensitivity analysis. Two studies were judged as moderate risk of bias and two as serious. Assessment of Grading of Recommendations Assessment Development and Evaluation resulted in moderate certainty in the outcome of motor success rates. Conclusions: BTX-A might be a good alternative to BMR in patients with PAET. Randomized controlled trials with larger sample sizes and longer duration of follow-up are needed. Studies should also focus on sensory outcomes in addition to motor outcomes.